I have often commented that the philosophy of natural mothering (natural childbirth, lactivism, attachment parenting) rests on fundamental assumptions that are often unrecognized and therefore unexamined. I’ve written about the social construction of risk within our culture and the social imperative that everyone (mothers and doctors) do everything possible to minimize risks to babies without ever considering the trade-offs that reducing specific risks imply.

But risk is not the only thing that is socially constructed within the philosophy of natural mothering. Women’s needs are also socially constructed; specifically, in the philosophy of natural mothering, women’s needs are rendered invisible. Natural childbirth advocacy and its approach to the issue of pain in labor is perhaps the paradigmatic example of the way in which natural mothering erases the needs of women.

Natural childbirth advocacy uses several different strategies to render women’s needs invisible. To understand how these strategies work it makes sense to start with the empirical facts that most of us agree upon:

1. Childbirth is excruciatingly painful. Indeed the pain of childbirth is so impressive that ancient cultures imagined that the only possible explanation was divine punishment of women for their transgressions.

2. Severe pain should be treated. No one would ever suggests that cancer pain be ignored or that pain from a broken bone should go untreated.

3. Medical professionals have an obligation to treat pain. Every human being is entitled to the medical treatment of pain if that’s what he or she desires.

Natural childbirth advocates employ a variety of strategies to render invisible women’s need for pain relief. The first strategy is to insist that a mother’s need for pain relief is insignificant when compared to the “risks” of epidurals. This strategy is all the more remarkable when one considers that the “risks” of epidurals are not empirical, but purely speculative. Presumably, the baby has a need and a right, to avoid any potentially harmful effects from epidurals that might be discovered as some unspecified future time. And that need (even though theoretical) trumps the mother’s need for pain relief, despite the fact pain of this magnitude would always be treated if it were from any other source.

The intellectual sophistry of such a claim is all too apparent. The natural childbirth project involves invoking risks that may not even exist and inflating both the severity and the likelihood of such risks. And it rests on the assumption that no matter how theoretical or how small these risks may be, they automatically trump a woman’s need for pain relief. A woman’s need for pain relief is therefore of no consequence and not even worthy of consideration.

Even when natural childbirth advocates concede that women might feel a need for pain relief, they employ a variety of strategies to diminish the importance of that need. These strategies involve

Blaming the woman for her own pain – if she did it “right,” childbirth would not be painful.Blaming the woman for not using “natural” methods of pain relief – regardless of their questionable value in providing adequate relief.Blaming the woman for not embracing the pain as an “empowering” aspect of her biological destiny.

Simply put, according to natural childbirth dogma, a woman’s pain in labor is irrelevant, of no importance compared to the baby’s need to avoid theoretical risks, and her own fault.

It is important to note that in natural childbirth philosophy, it makes no difference how small the risk to the baby might be, and it makes no difference how large the mother’s need for pain relief might be. To put that in perspective, it helps to consider another, far more trivial, example of balancing risk and need that all mothers must address.

Consider the issue of driving with a baby in the car. There is no doubt that riding in a car exposes a baby to a real risk of injury and death in a car crash, a risk whose magnitude is far greater than the theoretical risk of an epidural. And consider that the mother’s “need” to go to the grocery store is trivial, and can easily be met at another time without putting the baby in danger of injury or death in a car accident. So why aren’t natural childbirth advocates berating women for driving with infants in their cars? They consider that larger risk socially acceptable. In that case, convenience trumps whatever needs the baby might have.

The reality is that every choice has risks and benefits, and those risks and benefits must weighed against each other. But when a woman’s need for pain relief is rendered invisible, natural childbirth advocates can act as if there is no benefit to pain relief in labor and can pretend that no weighing of risks and benefits is necessary.

It is difficult to imagine any other situation in which ignoring a woman’s severe pain would be socially and ethically acceptable. But for natural childbirth advocates, a woman’s needs are invisible, and therefore merit no consideration.

Sort of OT.
28w appointment today for a growth scan.
Which was fine: baby is small, but ok for someone my size.

However, the OB (not my OB, who is on holiday) and midwife were… I’m going to go with judgey and brusque.

“So you had a CS before? What is the plan this time?”
“CS”
“Why?”
“Because I’m not comfortable with the risks of VBAC”
“And what about if you go into labour?”
“Still CS”
*weird unhappy facial expessions*
“And you’re a doctor?”
“Yes, so I’ve seen enough obstetric disasters to be sure about this”
*REALLY unhappy weird faces*
Then a whole thing about my back and pelvis and bladder and why did I have the first CS… more unhappy faces.

And then a scan which was AC, BPD, AFI and absolutely no effort made to, you know, make it a nice experience where we could see the baby.

“So your next appointment in six weeks… you’ll get a date for surgery, but you should think about your options”.

Going to request my own OB next time.
My husband was probably more upset than I was TBH, because he’d been looking forward to seeing the baby.

Allie P

I’m so sorry. Why are all women’s reproductive choices being taken away from them?

Daleth

That is so obnoxious. It reminds me of my own experience, when all but one of the MFM’s on my team were waving the vaginal birth pom-poms and trying to talk me out of a CS with my mono-di twins of whom one was breech or transverse at every ultrasound but one (and with mono-di twins, you get u/s every two weeks, so there were a lot). Matter of fact, reading that it happened to you too makes me think, maybe we should write to our respective hospitals to complain.

Do you think that would be worthwhile? I mean a professional-sounding, polite letter that thanked them for what was worth thanking them for, but also expressed serious concerns about the anti-c/s stuff.

Ash

Twin Birth Study randomly assigned women between 320/7ths and 386/7ths
weeks of gestation with twin pregnancy with the first twin in cephalic
presentation to planned cesarean or planned vaginal delivery. For women randomly assigned to planned vaginal delivery, 56.2%
delivered both twins vaginally, and 4.2% had a combined vaginal–cesarean
delivery. The remaining women (39.6%) had a cesarean section for both twins.. Now, the media trumpeted the study showing that overall planned VB was e safe for the babies in this cohort, but the news stories ignore that some mothers would rather have a planned pre-labor c-section rather than a trial of labor, given that about 43% of this group were delivered by c-section.

Roadstergal

Combined vaginal/caesarean sounds like a hell of a rough day. : Especially as that would likely be a rushed, emergency C-section?

Medwife

When there’s a twin birth with one vaginal, one by c/s, or a failed instrument delivery attempt followed by c/s, I feel so terrible for the patient. They get the worst of both worlds. Horrid recovery experiences.

Daleth

Yep. And that wasn’t even about mono-di twins, who have a much increased risk of certain complications, such as placental abruption when Baby A is delivered. That wasn’t something I was willing to risk, and I looked at the stats the same way you are: “Wait, I have almost a 1 in 20 chance of having BOTH a vaginal delivery AND a c-section to recover from, and close to a 1 in 2 chance of having to suffer through however many hours of labor only to end up with an emergency CS? NO WAY!!!”

Not to mention that as Roadstergal points out, a CS for baby B after vaginal delivery of baby A is highly likely to be a “minutes to spare” life-threatening emergency, along the lines of “omigod the placenta abrupted, we have to get B out,” so even assuming B comes through ok it’s still quite likely the most traumatic and dangerous type of c-section available–a crash section under general anesthesia. NO THANKS!!!

Medwife

I don’t understand how people think that behavior is ok. Imagine women who aren’t doctors, because at least they knew not to try to “educate” you out of your decision.

sdsures

Ugh. I’m sorry they did that to you. It’s really unprofessional.

Brix

Wow. What jerks.

Sue

As I’ve said before, people apply arguments about epidurals that they would never apply to general anaesthesia, even though the latter is more risky.

GSs are often done for non-critical procedures or tests. Rarely, people die. The response is to improve patient selection and safety, not to do procedures or invasive tests without anaesthesia.

Sarah

Very true. And no anaesthesia is totally risk free, there’s always a very small possibility of problems, but somehow only that used in childbirth is subject to this level of scrutiny.

Leeba Weisberg

I disagree with a few aspects of this piece. Childbirth is painful – often excruciating. On that I think we can all agree except some people with their heads in the clouds who insist they can wish away pain. However I disagree with the concept that severe pain should be treated. Severe pain should be treated if the person experiencing the pain desires the treatment. Women should not be pressured into forgoing pain relief in childbirth, nor should they be pressured into pain relief options they don’t want. There are reasons other than romanticizing birth or irrational fear of medicine for forgoing epidurals. Wanting to be mobile during labor, for example. Women need to be treated as individuals and our individual decisions respected.

SporkParade

With all due respect, many more women are being pressured out of desired pain relief than being pressured into undesired pain relief. I took a natural childbirth class and, out of 10 couples, I was the only one there for reasons other than a romanticized view of birth. On top of which, it’s actually in the interest of hospitals to have fewer women request epidurals because then they don’t have to have as many anesthesiologists on staff, or even, gasp, a dedicated L&D anesthesiologist.

Rosalind Dalefield

A fentanyl epidural allows full mobility, and you feel everything BUT the pain. I have given birth with no pain relief and with a fentanyl epidural, and a fentanyl epidural was much better in my experience!

SporkParade

Yeah, but not all places are equipped with walking epidurals.

sdsures

How does it work? I don’t understand (not a doctor or nurse here); I mean, I know what fentanyl is, but do not understand how or why it’s used instead of a “regular” epidural.

Allie P

A lot of women who “choose” not to have pain relief have been lied to and manipulated by a natural childbirth propaganda machine that tells them they are hurting themselves, hurting their labor, hurting the baby, ruining their “birth experience”, not being strong, not being real women…. you name it. The question of “pressure” only occurs because women are being told that foregoing pain relief in labor — and ONLY in labor — is a virtue. Where are the campaigns saying we’d all be better off visualizing and breathing through our gallbladder surgeries for women to start refusing pain meds for that?

Rita Rippetoe

Actually, my grandmother tried to convince her doctor to remove her gall bladder with only local pain relief. He was astonished at the request and talked her out of it. She was in her 70s at the time.

JJ

Thank you Dr. Amy. I hate how NCB makes you feel like a terrible mother (before you are even holding the baby) for considering your own needs. I crushed my shoulder as a child and I barely cried but I still got pain relief, of course! I screamed and thought I was dying during my first labor but I had been trained that I had to sacrifice myself to not drug/hurt my baby. There was no risk/benefit. The benefits to me did not matter = I DID NOT MATTER. That unhealthy mindset really sets the precedent for how you mother.

CharlotteB

Dr. Amy, today is my son’s first birthday, so I’m naturally thinking about his birth, and this first year of parenthood. I just want to say THANK YOU for writing. Because of you and the commenters:
1. I knew to expect labor to be painful–granted, it was FAR more painful than I’d imagined, but I’d guess that’s true for many (most?) first time moms.
2. I knew I could trust my CNMs and nurses (and OB, if I saw one) to put my health and the health of my son first. I knew there are far, FAR worse outcomes than a C-section.
3. I saw the hospital as a safe place. Even when the nurses had to be firm with me, I knew they were doing their job, and that they weren’t being “mean” or showing a lack of trust in my abilities as a woman. They wanted me to go home in one piece, with a healthy baby.
4. I learned, from you, that my value or abilities as a mother have nothing to do with the biological function of my breasts or vagina. I learned that having a straightforward labor and delivery was luck, not anything I did, and that because there’s no way to win at birth, there’s also no way to fail.
5. I learned that giving my son formula was a good, healthy option. While I was disappointed (at the time) that EBF didn’t work out, I didn’t feel guilty or like I was a failure for giving him a bottle. Rather, I enjoyed the breastfeeding I did, and felt grateful every time I made a bottle that I didn’t have to hear my baby cry from hunger. And I felt zero guilt for stopping at 10.5 months simply because I didn’t enjoy it anymore.
6. I saw that a perfect, healthy baby (and living, healthy mother) is a MIRACLE, not a given. Reading about the things that can go wrong, and the many things that can be done to save a baby or mom, AND reading about some of the limits of medicine has made me profoundly grateful to have had access to medicine in a first-world country.

So thank you for standing up for women’s real rights in childbirth–the right to accurate information, the right to pain relief, and the right to bodily autonomy. Thank you for telling the truth, and for trusting that women can handle it.

Amen, sister! I couldn’t have written it better! Consider this my Disqus up vote!

Sue

Wonderful post – thank you!

For me, and I imagine for most of us, THIS is what Dr Amy’s blog, and pro-science sites in general, are all about.

The zealots are rarely converted, but good, logical information does help those who have the insight to receive it.

dbistola

Can someone help me out here? I’ve been going back and forth with a person who I am sure is a lactation consultant online. Among her many claims, she says that neonatalogists regularly work in tandem with lactation consultants. I told her I have never seen or heard anything like that (my kid was in the NICU) and that proper feeding of an infant should be advised by a pediatrician or neonatalogist. She says that lactation consultants are more experts in infant feeding.

I told her that an LC was not a medical endorsement unless it was followed by MD or RN. I have been checking online and I don’t know. Is it a medical endorsement?

MHAM

When my daughter was in the NICU, there was an LC on the medical team. She was also a nurse practitioner, so she had the CRNP designation. The hospital had a large lactation team, all of them RNs or CRNPs. She was specifically assigned to the NICU and met with us frequently, both one on one and with the neonatologist present. They seemed to have a good, professional, collaborative relationship.
But we were not having any issues related to feeding. Breastfeeding had successfully initiated and was progressing smoothly. So her role was more helping to facilitate breastfeeding and pumping around the other important care that was taking place.

dbistola

But is the LC in itself a medical endorsement?

Mattie

I think IBCLC is a healthcare qualification, buuut I don’t know how rigorous the training is, what pre-requisites a person needs to do the course or anything else, it’s not the same as an RN qualification, but it is a qualification.

Mattie

I think this is…tricky, because there are SOME very good LCs who do work in collaboration with parents, NICU staff and other hospital personnel to help a mum who wants to breastfeed feed her prem/poorly baby. These LCs do not need to be RNs or MDs to be good at their job, however they also need to not be super crunchy. NICU babies often need stricter feeding schedules than other babies, and as such supplementing may be needed…you can’t have a crunchy LC telling you not to do that, and I think the other staff would have an issue with that too.

dbistola

But would you listen to an LC before a doctor?

Mattie

It depends, infant feeding is about parental choice…if a mother wants to feed her NICU baby breastmilk then I’d imagine a good LC would be a useful asset, and they may have more experience with the practicalities of starting and maintaining a milk supply while a baby is in NICU…the doctors/nurses would likely set the feeding schedule, but the LC may be more help in the actual ‘feeding’ problems/support.

However if LC was saying ‘do not supplement’ and neonatologist was saying ‘this baby needs more food than you have’ I would go with the doctor. Doctor for health, LC for ‘practical’

I would go to the neonatologist for what type and volume of feeding the baby needed, and to the LC for how to best to extract milk from breasts, if that’s what was desired or needed.

dbistola

Would an LC be able to diagnose an issue in an infant, or prescribe a certain kind of feeding, or is the job only tied to lactation?

D/

Since there is no universal licensure requirement, “lactation consultant” can mean anything from a self-declared breastfeeding enthusiast with no actual training to an IBCLC with (oftentimes required) additional healthcare credentials such as an RN, nurse practitioner, registered dietician, or even an MD …especially in the hospital setting and especially in the NICU. IBCLC certification is a specialized healthcare certification and eligibility requirements can be found here: http://iblce.org/certify/eligibility-criteria/

I am hospital-based RN (certified in neonatal intensive care nursing) and IBCLC and work in collaboration with neonatologists on a daily basis. I am absolutely a member of the NICU team and am considered the expert in the clinical management of breastfeeding. Having said that, as an IBCLC (or even as an RN) I cannot diagnose or prescribe treatments for medical conditions. That falls under the practice of medicine and is the realm of physician/ advanced practice nurse in the NICU setting.

“But would you listen to an LC before a doctor?” I would NEVER even consider putting a parent in the position of facing this possibility. Any differences in opinion on clinical breastfeeding management relative to a baby’s medical treatment is addressed between myself and the physician. IMO if I can’t present a convincing enough case for whatever I’m advocating as the lactation plan of care directly to the neonatologist then it has no business happening in the NICU anyway.

fiftyfifty1

“IMO if I can’t present a convincing enough case for whatever I’m advocating as the lactation plan of care directly to the neonatologist then it has no business happening in the NICU anyway.”

Exactly. And that’s what being a professional means. If what you have to say is important AND backed with good evidence, then you bring that up to the rest of the team. A convincing case is convincing.

FEDUP MD

Lactation consultant is like saying midwife. With midwives, you have some who are essentially NPs, who work hand and hand with OBs and are very science based, and some who are poorly educated “professional” midwives who have no idea what they are doing and are ideologically based. I have had the pleasure of working with LCs who are similar to the former. They were also RNs.
In pediatric residency and practice, you are not really taught a lot about how to actually make breastfeeding happen, or how to pump. As a first time mom, even as a board certified pediatrician myself, I could barely figure out how to put the pump together, or if the baby was actually getting milk or not when feeding for a given feeding, how to position the baby so it was comfortable with my c-section incision, etc. I knew to feed on demand, not to time it, blah blah but how to actually do it? And if I was doing it right? Not sure.

So the LCs helped me with all that. The pediatrician and I together made decisions about supplemental feedings when the babies lost too much weight. But he did not help me with the mechanics of HOW to feed the baby practically. Which makes sense, seeing as I would really consider that well within a nurse’s scope of practice as patient educators.

So in a NICU the neonatologist will order the initiation, type, and amount of feeding. If it involves maternal breast milk (MBM) the lactation consultant will help the mother to produce it by pumping to get the amount needed. If the baby is cleared to breastfeed the lactation consultant will help the baby to learn to do so (my LC helped mine to overcome an oral aversion due to instrumentation/intubation). The doctor makes the final decisions/orders for feeding (with lots of input from nursing and other staff) and the LCs figure out practically how to make that happen. Just like in many things in medicine, 🙂

FEDUP MD

Which leads me to point out most people have NO idea about nursing scope of practice vs. physicians. We had risk management the other day in a meeting asking us about standardizing how fast to give certain IV medications, how to mix them, what they could be mixed with, etc. and we just all looked blankly at them. Finally someone pointed out they should probably take that to a nursing meeting, because that is what they do all day and is their scope of practice. We just say what medicine, how much, and how often, and then the actual work of doing it and getting it in is done by nursing. If they all left the hospital I would be screwed as I barely can figure out how to turn off the alarm on the IV pump, never mind anything like actually using it. Plus I would have no idea what was going on with my patients because nobody would be monitoring them, and the patients would have no idea what was going on with their care, because I can only spend a few minutes a day in their rooms.

That is EXACTLY what I discovered during my sabbatical year when I audited some med school courses. The med students knew all the correct theory, bu had little or no practical knowledge at all. In Pharmacology lab I found myself teaching them how to take blood…

lilin

I always enjoyed the breastfeeding catch-22. If you breastfeed right it doesn’t hurt. If you think it does hurt it’s because you’re not breastfeeding right. Anyone who says breastfeeding can be painful, therefore, cannot say breastfeeding can be painful, because if breastfeeding is painful they weren’t doing it right, because breastfeeding done right isn’t painful.

It just keeps going like that.

MegaMechaMeg

If everything appears correct and it still hurts just start cutting things in the kids mouth and hope for the best.

fiftyfifty1

Or have the mom go on a month course of fluconazole pills and paint the child’s mouth with gential violet daily, because the breast ducts must be overgrown with hidden thrush (although there exists absoluetly no evidence that such a thing exists).

araikwao

There is some newish evidence on it (I only know because it was done by a lactivist-type doc and researcher where I did my ob/gyn rotation and the LCs were very excited about it). Can’t remember details tho, sorry..

Wren

Actually, the cutting things in his mouth might have sorted things out with my first.

guest

And when you do live without a car, people look at you like you have two heads. I’ve gotten the distinct impression that people questions my parenting since I can’t drive my children to all the places they do. I wish I could, but we don’t have a car because it isn’t necessary, and we can’t afford it. I don’t think not being able to go out of town for the weekend is a terrible privation for my children, though.

Wren

We didn’t have a car when we lived in London, even with a child. We do need one where we live now though.

guest

Oh, I get that it’s needed in some places, but definitely not where I live. But it’s the people where I live who I get this attitude from. As I said, I wish we could have a car, but at least I get the consolation prize of knowing that our risk of being hurt or seriously injured in a car accident is much lower. Although it’s not null, of course, since we can still be hit as pedestrians, or we go for one of our rare trips in a cab and just aren’t lucky.

The Computer Ate My Nym

No one would ever suggests that cancer pain be ignored or that pain from a broken bone should go untreated.

Sadly, it seems that they do. One of the most disturbing things I heard at a recent meeting is that 67% of the world’s population live in places without access to opiates. That means no opiates for broken bones, none for cancer pain, none for post-op pain. In many places, opiate access is inadequate not because of flat out lack of resources, but because of unwillingness to utilize those resources for pain relief or political opposition to “recreational drugs”. (Caution: Some, but not all, of the information came from a company whose main product was inexpensive medications, including opiates, that they were trying to provide to patients in poorer countries.)

araikwao

I believe it. I worked in a developing country as a physiotherapist and went to see a lady day one post-trans-tibial (below knee) amputation. She was reluctant to move, and that may have been due to having NO post-op analgesia….not even paracetamol ☹ and that was all I could get them to give….

Stephanie

In addition to pain relief, the other consideration that is frequently ignored in natural childbirth circles is future sexual function. Tearing is promoted as natural, and it is still considered normal to have mild incontinence following childbirth. It is very rarely discussed that there is a very real risk of trauma and dysfunction to our sexual organs from a vaginal delivery. When a woman brings up that she does not want to risk trauma to her sexual organs, she is considered “Too Posh to Push”.

Amy M

Same with breastfeeding–any pain the mother may experience is 1)her fault for doing it wrong, 2)worth withstanding, for the baby’s sake and 3) probably just the mom looking for an excuse to “avoid saggy breasts.”

Well, I don’t know for sure if breastfeeding definitely leads to saggy breasts, but if it does and a woman wants to avoid that, that’s her decision to make. Negative body image can certainly lead to sexual dysfunction.

Mattie

I may be wrong but I think it’s just pregnancy that causes saggy/saggier breasts, although BFing for some women can lead to much smaller breasts, not sure how often that happens though.

Who?

Age will do it. And mine are bigger than they have ever been, despite a bmi of 21-22, and the rest of my body being more or less the same proportions and size as it was 20 years ago.

Kelly

I always joke that I will be able to tuck them in my pants when I get older. They are already huge and saggy from pregnancy and I am in my early 30s.

Amy M

I think its gravity and time mostly, but I could see how breastfeeding (lactating) could contribute. I have friends whose boobs were in the J/K range when they were breastfeeding. Getting all stretched out like that and then shrinking back to a DD or less when nursing is through can’t be helpful. I didn’t really breastfeed, so my boobs went back to pre-pregnancy size within a couple months. Now, more than 6yrs later, the size hasn’t really changed but they are definitely saggier, when sans bra. This isn’t a big deal to me, because I have some excellent bras, but I could see how a woman might see the changes that pregnancy and time has wrought on her body and feel disgusted.

MegaMechaMeg

I read an Alpha Parent article once where she claimed that there was no physical reason why someone with Reynauds of the nipple could not breastfeed. That was actually the moment where I ceased to take her seriously.

Mattie

you can get reynauds of the nipple….ouch 🙁

Chi

You can and it HURTS. Especially in colder weather because nerve endings have been damaged and the only way to ease the pain is paracetamol (because that’s the only meds you’re allowed while breastfeeding, although I my doctor gave me a synthetic opiate tramadol as well because I begged her because the pain was unbearable) and standing under a HOT shower.

And yes it is excruciating. I personally felt like I was being stabbed by tiny burning pieces of glass, and the pain started at the nipple then would shoot around the side of my body right to my armpit. It was NOT pleasant, and I can certainly understand why some women would want to stop breastfeeding as a result.

Megan

Yes and having experienced it, I can tell you it’s very painful!!

MegaMechaMeg

You can also get this thing where anything that touches your nipples sends you into a depressive or rage filled state. They say it is caused by the hormone drop of letdown and she didn’t think that was a problem either.

Mattie

:O that sounds horrible

Puffin

Agreed completely. I had a pretty serious tear with my first. My midwives did not stitch it and assured me that it was normal during my recovery period even though I complained of significant ongoing pain. It wasn’t until I had surgery to fix another mistake of theirs that it was mentioned to me by the OB caring for me that the tear was very much NOT normal and absolutely should have been stitched immediately as by then it had healed too much to fix without a separate surgery. I feel almost like they were punishing me for getting an epi.

I’ll be having reconstructive surgery after I finish having kids. It has caused pretty significant issues and has opened and torn further – requiring at least a month to heal each time – five times since my first was born the better part of a decade ago.

Sarah

There’s nothing wrong with having a torn clitoris.

MidtownParent

Dr. Amy, would you consider a related post about the delays that women are forced to endure in getting an epidural v. actual science on the topic? Many women are forced to wait until “active labor is well-established,” and experience very significant pain by that time. I know there is some current research about whether this is still a best practice, and would love to see a qualified OB’s assessment on it.

ACOG also says that epidurals should be given on demand. Many LDRs won’t give epis until 4 or 5 cm tho. In my community, this is not a medical issue so much as a resource issue…when LDRs are generally usualy full administrators have pressure to keep women out until they are confident that they will deliver in 6-12 hours. Its expensive care 1-1 nursing for example. The result is that women are not adequately treated for their pain and often sent home after IM morphine or pethidine or something similar…still in considerable pain. I’m not sure what the rationale for delaying an epidural is in places where you can be admitted to LDR in early labour with a low risk pregnancy. here you have to be a primip > 4 cm regularly contracting to get in and they often try to apply that to multips too. If you don’t want to go you can walk around and return to triage but aren’t admitted/given a gown/ etc.

EllenL

Societies fund what they value. If women’s needs are a value
(or a priority), there will be enough beds, there will be enough anesthetists.

guest

Except for when there’s not. I had a bed to labor in, and an OR for surgery, but afterwards there was no bed for me in antenatal (where I had to go for magnesium monitoring), and then the bed I did get was broken and did not raise or lower properly, which was hell on my incision – all because it was just really busy at the hospital, because a hurricane had shut down another local hospital.

MegaMechaMeg

Well that is the most accurately depressing thing I have read today.

SporkParade

The same rationing happens here. Do you have any insight as to why progress of labor is defined by dilation? I’m curious because my contractions were 1 minute apart at only 2 cm dilation and it hurt like hell, but they still wouldn’t admit me because I wasn’t at 4 cm yet.

Cobalt

Too many women stay at 1, 2 or even 3 cm dilation for days or weeks before labor actually starts, would be my guess. It may not be “normal” but it’s pretty common. Not a good reason to ignore someone presenting in excruciating pain, though.

Amy M

I was 4cm dilated from 32wk to when my water broke at 36wk. No pain, not even when said water broke.

fiftyfifty1

“Do you have any insight as to why progress of labor is defined by dilation?”
Because of predictability of further dilation. If a woman is at 5cm and having contractions, she is said to be in “active labor” and predictably will continue dilating fairly rapidly unless there is a true medical reason that prevents it. But if a woman is only 2 or 3 cm, what will happen is very hard to predict, even if she is having regular contractions, and especially if this is her first birth. For a woman at 4 or fewer cm it is fairly common and completely normal for labor to stop, or for her to continue with regular contractions but make no discernable progress, or to continue and make rapid progress and everything in between. It’s like a sled. At the top of the hill it’s easy to stall out or just inch along. But once the sled gets going, it doesn’t stop (unless a physical barrier hangs it up).

Mattie

Sort of related, I had a debate with a new OB on our university fem so facebook page about how it’s wrong to deny a woman pain relief (including epidural) if she requests it, and also to refuse to admit a woman without a VE to confirm dilation. My argument is that a VE is a procedure and as such you must have informed consent, if you’re using a VE as a ‘gate keeping’ tool, you can never get fully informed consent as you’re refusing access to things unless the VE takes place…that IMO is coercive. ‘You don’t have to have this procedure, but if you decline you can’t get care/pain relief/etc…’

Thoughts? Am I wrong…was she?

fiftyfifty1

I’m confused. Why would the woman be refusing an admit VE? It really ties a doctors hands not to have access to such an important piece of medical information. The VE gives important info on everything from dilation, to ripeness of the cervix, to is the baby head down and pressing on the cervix well to is the amniotic bag fully intact. Refusing a VE is like somebody presenting for chest pain and refusing an EKG. If a woman has a sex trauma history, then a plan for what to do about the VEs should have been worked out before hand. To just show up and start refusing to cooperate off the bat is really juvenile.

Mattie

Yeh, reasons could be previous sexual trauma, too much pain at time of arrival at the hospital, or simply exercising her right to refuse a medical procedure she does not want/feel comfortable with. I just don’t see how a procedure can be fully consented to if you don’t actually have a choice…sorry you didn’t consent so you’ll just have to have your baby in the car park.

VE is notoriously subjective, so it has had its effectiveness questioned (although AKAIK it’s not been shown to be ineffective, just not especially effective either) and there are other non-invasive ways to gauge labour progress (maternal behaviour, contraction length, strength and the ‘purple line’). But to me, using a VE (which is an invasive procedure) as a requirement to pain relief and care is coercive…

fiftyfifty1

Let’s see where this idea of yours leads:

I refuse to let you do a VE (because I choose to believe NCB propaganda that claims it is ineffective rather than mountains of real evidence that proves its utility).

I also decide to refuse an abdominal exam (because I have modesty concerns).

I also refuse to let you hook me up to a contraction monitor (too uncomfortable for me).

Like hell I’m showing you my butt crack (for my own private reasons).

Instead I insist that you admit me to the hospital based on my agitated behavior. I insist that you give me pain meds. I insist on an epidural. If the baby is not born after an amount of time I deem correct, I still refuse exams and I insist on pitocin. If the baby is still not born I insist on CS.

Reflexive defiance! A great way to start your journey as a mother!

Mishimoo

Not to mention, it seems a bit ridiculous to demand assistance while at the same time denying medical professionals the information they need in order to treat their patient/s efficiently and safely.

fiftyfifty1

“while at the same time denying medical professionals the information they need in order to treat their patient/s efficiently and safely.”

Ok then, I take it back, I will let you peek at my “purple line” after all.

Mishimoo

Thank you for allowing me into your circle of trust, powerful warrior mama!

There is a folk belief in lay midwife circles that vaginal exams are useless because women in natural labor will develop a purple discoloration in their butt cracks that will grow in proportion to how far dilated her cervix is. Mattie advocates, above, that doctors observe this mythical line rather than do VEs.

Ash

I was trying to make an allusion to “The Thin Red Line” 😉

Mattie

No, not a great way to start, but your right as an autonomous human to do so…and whether the doctors like it or not they have to provide care, because not providing care of some sort is negligent. I don’t think that a woman could insist on pitocin but she could insist on a c-section. A c-section would in fact negate the VE argument, as you don’t have to be in established labour for a section. If (as in my example) a woman does not want a VE because she is in too much pain then some form of pain relief could enable you to perform a VE more comfortably.

I’m just curious as to what you would do if a woman refused to consent to a VE, yes it would make your life difficult as a care provider, it would also increase the risks to the mother and the baby. However, you’ve told her all this and she still refuses, do you try and convince her to change her mind…because that’s not informed consent. Just because VEs are routine and necessary doesn’t mean that they don’t require the same level of consent as anything else.

fiftyfifty1

Sure, it’s your right to refuse anything. You can be as uncooperative as you want. The problem is there is a whole movement devoted to encouraging women to just this in labor by telling them lies. Lies like the ones you yourself are spreading where you say OBs are just doing VEs out of ignorant habit and that they are unneeded, invasive, dangerous and that the info they provide can be gotten other ways like the “purple line”.

Go ahead. Keep telling women lies, scaring them away from the care that can save their and their babies’ lives, and then dress yourself up as being a champion of ethics and patient autonomy.

fiftyfifty1

“However, you’ve told her all this and she still refuses, do you try and convince her to change her mind…because that’s not informed consent.”

What are you saying? That proper informed consent requires that we not try to change a person’s mind? Try arguing that definition to a court of law.

The truth is that trying to change a patient’s mind in a dangerous situation is part of a physician’s ethical duties. It is also an ethical duty to do no harm. And admitting a woman to L&D and giving her an epidural without checking to make sure it’s safe first by doing a full exam is breaching that duty. Courts call it malpractice.

Once again, this is the central problem with NCB. It encourages women to be unreasonable, uncommunicative and deceptive. It encourages them to show up and start refusing needed care by telling them lies about what is needed and lies about OBs’ motives. It deliberately creates miserable ethical dilemmas and calls that patient empowerment and feminism.

You can debate as much as you want on your university fem so facebook page. You can rile up as many women as you want and imagine you are a champion of women’s rights. But really, that makes you a dangerous jerk. The young OB you debated has actual experience, has devoted herself to years of education, has likely taken far more training in real ethics than you have. You are a walking, talking example of Dunning Kruger.

Medwife

Hm. What about a woman who is contracting powerfully, painfully, and frequently because she has a placental abruption? If it’s occult there won’t be frank vaginal bleeding, but she’ll be contracting like she’s in transition when she’s at 2 cm. Not doing a VE could lead to a significant delay in diagnosis. Read: a dead or disabled baby, and a doctor who will get his or her ass handed to her on a plate in court 1-18 years down the road. Doing a VE on presentation is standard of care and you can bet a woman won’t have a hard time arguing she didn’t REALLY understand the risks of not getting a VE done.

Cobalt

A VE is the cheapest and simplest effective way to determine cervical status. You could request ultrasound, I guess, but it would have to be transvaginal in order to get the right measurements.

You cannot effectively treat in the absence of exams. Accurate information is needed to determine if or what type of treatment is necessary, beneficial, or potentially harmful. It makes no sense to blind your healthcare provider.

Also, maternal behavior and contraction pattern are very unreliable. I have twice been shocked by a “let’s just see what your cervix is doing” exam at the doctor’s office revealing I am at least 5 cm dilated without having an identified contraction. I felt fine. So fine the nurse was sure I wasn’t in labor even though my doctor sent me in. I didn’t have contractions 5 minutes or less apart until the baby’s hair was visible.

At the other end of the spectrum, there are women in absolute agony, with closely spaced and very painful contractions, for hours without dilating beyond a centimeter or two.

guest

I’ve read a lot of accounts of home birthers wanting to avoid VEs, and praising their midwives for not doing them. I found that how much they sucked depended on who was doing them. And also the knitting needle things used to rupture the amniotic sac. Those are horrible.

Anyway, I did not refuse any during my pregnancy, but if all of them had been as painful as the one one male doctor did (before I was even in labor) I can see why women would want to, especially if they are done before pain relief can be provided.

Allie

As a cardiologist I can only confirm what the poster below says. When you come in stating you have chest pain but refuse to let me take an ECG, I’ll still be happy to tuck you into a hospital bed. However, it wouldn’t do you any good because I have no clue what is actually the matter with you so you won’t be getting any proper treatment. I won’t cath you without an ECG.

I imagine it’s the same with saying you’re in labor and refusing to let anyone check if that is in fact true and if yes, how far along. No sensible anesthesiologist will go near you with an epidural needle if the diagnosis of labor is not established. For all he knows your pain is from something else entirely and that epidural will turn out to be blantant malpractice.

Mattie

I guess it’s a difference in procedures as well, ECGs are non-invasive and essentially painless. VEs can be painful, are invasive and carry a risk of infection. I can see that you would need to make sure the woman is in labour, but that can be done with a CTG or abdominal palpation (which can also check for other problems). If epidural doesn’t require a specific dilation to be effective, and we should be admitting women who feel they can no longer cope at home…what purpose does an admit VE actually serve…or at least, why is it not optional?

Phascogale

A CTG or abdo palp will in no way tell you whether you are in labour or not. All a CTG will do is tell you whether the baby is okay at the time of the CTG. And there are many women having painless tightenings that feel reasonably strong but not in labour.

fiftyfifty1

“And there are many women having painless tightenings that feel reasonably strong but not in labour.”

To which I will add that there are many women having *painful* tightenings that feel strong but are not in labor. My sister-in-law went into triage at 38 and 38+2 with regular painful contractions, and stayed there for enough time to determine, though serial VEs, she was in false labor. She finally delivered at 40 weeks.

Who?

Especially with the first one-those Braxton whatevers felt like the real thing until the real thing, when ‘pain’ took on a new and dramatically expanded meaning.

Cobalt

I had very regular (set a clock by them) 1 minute duration, 3 minute interval Braxton-Hicks contractions for hours every evening. They hurt quite a bit. On paper, they looked just like labor, except they always stopped at some point overnight and there were no cervical changes.

When I went into labor, I felt very vaguely, but not painfully, crampy and like I needed to pee. And dilated without even realizing I was in labor. I have no faith in pain as a reliable indicator of anything other than pain.

Wren

I cannot tell you when I actually went into labour with my second. I had Braxton-Hicks contractions whenever I did much of anything active from 35 weeks on. The day before she was born, my mom arrived from the US so I was active all day. I had contractions every 10 minutes all day, just like I had whenever I was active for weeks before that. Somewhere around 2 am they got closer together but still weren’t really painful. By 5 am they were painful and gave me about 20 seconds between them. I was 10 cm when I got to the hospital.

guest

I was in the hospital overnight about a month before my labor for urine testing and the monitors kept showing contractions. The doctor said, “Did you know you were having contractions?” No, I absolutely did not. And I didn’t really believe him because I felt nothing (and also he sent me home about an hour later). I sure as hell felt my actual labor contractions, but whatever the monitor was showing that day was strong enough for a doc to call a contraction, but not causing me any pain. The body is weird.

fiftyfifty1

As I have detailed to you below, the VE gives the OB a lot of vital info, not just dilation.This includes presenting part. Have you ever had the experience of doing a VE in L&D triage and feeling …..HOLY SHIT THE CORD!!!? No of course you haven’t. You are all about Dunning Kruger and reflexive defiance.

Mattie

I haven’t personally felt a cord, but I do know the complications of cord prolapse and the speed at which you would need to act. I however also understand that for some women, VE is not an acceptable procedure (to them) and I don’t think those women should be denied care…Once a rapport has built up with the healthcare provider then the woman may be more comfortable accepting a VE, I mean if a woman is refusing VE then you can’t do it anyway…so what would be done in that instance?

fiftyfifty1

” I mean if a woman is refusing VE then you can’t do it anyway”

This brings us back to why would a woman refuse a VE? They refuse VEs because people like you lie to them and tell them it’s potentially dangerous, an “invasive procedure” and totally useless.

“…so what would be done in that instance?”

You advocate that a doctor is obligated to stop trying to convince her, admit the woman and give her an epidural. The truth is that the doctor cannot be forced to provide unsafe care. As others have explained, giving an epidural without knowing a woman is in labor with a straightforward vertex presentation is malpractice. The pain could be biliary colic or bowel obstruction, the presenting part could be a cord.

At best the woman could be admitted for observation, but much in the way of medicines could not be given. Anything more than a small amount of narcotics would be contraindicated because if the baby is about to be born there would be respiratory depression. And an epidural is also contraindicated for the reasons described above and by others.

tl;dr- the woman has a right to refuse anything she likes, but docs have no obligation to provide her with non-indicated interventions such as narcotics or epidural.

Sarah

You’re being a little harsh by only identifying that one reason why a woman might refuse a VE. There are plenty of us who find them physically painful due to gynaecological conditions, psychologically problematic due to experiences of abuse, or both. I find VEs rather horrific for reasons I don’t wish to go into, but I will tell you it’s got sod all to do with NCB. Some of the worst moments in both my extremely difficult and painful births came when undergoing VE. I accepted the VEs because I knew there’d be no pain relief otherwise, but in many ways it’s not true consent for the reasons Mattie outlined.

I accept that it’s not safe to administer an epidural without VE, to the extent that I wouldn’t have wanted one without it. But please understand that there are many reasons for refusing VE and plenty are entirely unrelated to NCB attitudes.

fiftyfifty1

Find VEs especially difficult for whatever reason? Screw up your courage and discuss this problem with your OB far in advance. If even having such a conversation is difficult, bring a support person or write your thoughts out ahead of time. Come up with a plan together as a team. Maybe the total number can be minimized. Maybe there is a position that works better. Maybe they can all be done by the OB himself or herself rather than by any L&D nurses. Maybe the OB can wait for pain meds to be on board before doing the more uncomfortable, extensive VE where s/he palpates the bones on the baby’s skull to determine alignment.

But don’t do what Mattie suggests which is show up in labor, refuse a VE and demand an epidural.

Sarah

I didn’t do what Mattie suggests- did you not see the part where I said I underwent the VEs and wouldn’t want an epidural without one? I also said I didn’t want to go into why, so I don’t think you should have asked the question. Additionally, I was happy to discuss the reasons for my difficulty with the clinicians involved in my care: I don’t, however, feel the need to disclose that information here.

As I shan’t be having any more children it’s a moot point, but I will say that the suggestions you raise would not solve the problem. For one, I’m in the UK and one doesn’t meet the OB/midwife who’ll be delivering the baby in advance. My first labour was lengthy and difficult and of necessity involved a number of VEs and a foetal clip that kept coming off and needing to be reattached. My second was short but involved a baby in distress and lots of meconium prior to the EMCS, hence several VEs. I don’t believe any of that could have been dispensed with, if I did I would not have consented. Support people might or might not be useful to a woman where the problem is psychological, less so when it’s physical. Positioning was not the issue, and the limited pain medication available in labour without VE would, for many women, not be sufficient to take away the physical pain such examination entails. Many women, including those who have no truck with NCB, have difficulty with VEs for a myriad of reasons and plenty of these are not solvable. That needs to be acknowledged.

fiftyfifty1

I’m sorry, my use of “you” in my reply was a general “you” and I should have substituted “one” to make it more clear. Rereading it now it sounds like I am accusing you specifically which is NOT what I meant. And I want to be clear, I am not asking you for your reason why, that is between you and your provider. OBs meet people all the time with very understanable and important reasons that VEs are especially hard, everything from history of abuse, to anatomic abnormalities, to vaginismus to vulvar vestibulitis to infibulation. They are typically glad to do their best to make whatever accommodations they can to make it easier on a woman. And this is true even in a call pool. the plan can be placed in the chart.

YOU faced the problem like a mature adult. You knew that it would have been nice not to need VEs, but you talked to your provider, found out why they were needed, and the team did their best to minimize them. You did the exact opposite of what Mattie suggests which is hide the problem and then show up refusing VEs and demanding everything else, assuming that docs just do VEs for their own jollies or to lord it over their patients (which is extremely offensive)

Sarah

Apology accepted, but your stance is still problematic because you’re associating ability to deal to some extent with the problem with maturity. That’s just not the case. Some of us experience more pain and/or trauma than others, some of us cope better with that than others. Some of us are more frightened of disclosure than others, some of us don’t have the opportunity to disclose prior to the birth. I am not a more mature human being than other women who find VEs similarly awful and were unable to tolerate them in labour.

fiftyfifty1

“When you come in stating you have chest pain but refuse to let me take an ECG,”

Although of course this never happens. Because there is no cardiac parallel to NCB. No movement of petulant idiots brainwashing you into believing that cardiologists have no idea what they are doing and encouraging you to defy their recommendations and take the advice of lay cardiologists instead.

Wren

There’s no movement, but there are people who won’t listen to a cardiologist. The thing is, those people just don’t go to the doctor. They aren’t like NCB refusing advice then relying on the doctors to save them.

Megan

Actually plenty of them do refuse all medical advice and then rely on cardiologists and hospitals when they finally have a heart attack. It’s kind of like the diabetics I see who think if they just don’t check their sugar and ignore it long enough it will go away. Then they wonder why they can’t feel their feet, have chest pain, can’t see, or end up in the ER in DKA. There’s a lot of “head in the sand” mentality out there, especially in my rural area where a fair number of people don’t trust doctors as a whole.

pinky

There are other ways of knowing a woman is progressing in labour without needing ve. Observing her behaviour, palpating her contractions and in some women, observing the purple line, can give you a clue. Ve is just a snap shot of now. It’s also not all about dilatation; you also need to assess descent of the pp, position and effacement of the cervix.

fiftyfifty1

“you also need to assess descent of the pp, position and effacement of the cervix.”

All of which are assessed with the VE.

“There are other ways of knowing a woman is progressing in labour without needing ve. Observing her behaviour, palpating her contractions and in some women, observing the purple line, can give you a clue.”

A clue. A guess. A guess that will be wrong a lot. Some women feel pushy at 4 cm. Other don’t feel pushy ever. Some rare women are never in severe pain. Other women are in severe pain at 2cm. Sometimes contractions palpate hard and regular but the cervix doesn’t change. Other times the contractions are widely spaced, irregular and weak and the cervix dilates rapidly anyway.

But why list all these facts? NCB types won’t believe them no matter what an OB says, because it’s all about reactive defiance, and you’re not the boss of me.

Monkey Professor for a Head

I was thinking about this post yesterday – had a baby last night! And funnily enough it ended up not dissimilar to what you’re describing. I started contractions at 2am, which got fairly quickly close together so went into L&D at 6am. I was 2cm then and was given the option to go home but since the contractions picked up when I tried to walk, I decided to stay in. Because I wasn’t thought to be inactive labour, I was moved to the maternity ward where I stayed for about 12 hours, having increasingly painful but very irregular contractions. Several times I asked for pain relief but was told I could only have paracetamol until I was over 4cm and in active labour, but because the contractions were irregular and were at times over 6 mins apart, they wouldn’t examine me. Eventually 12 hours post the first exam, I had a series of severe contractions one on top of another and had some pushy feelings. When they examined me I was 7cm and was moved straight down to L&D where I had a wonderful epidural finally and was able to calm down significantly. Perhaps it slowed things down (I needed some syntocinin and even with that my contractions were variable) but it gave me back control, and when I had some complications I was very glad of it. I really wish they had examined me earlier as not doing so lead me to have hours of untreated pain and severe distress, but everything worked out in the end and me and baby are healthy which is the most important thing!

Adelaide

My rural hospital wouldn’t admit me when I was 2 cm dilated and water intact with my third child at 38 weeks. I had a history of second stage labors lasting no more than 5 minutes. I was in severe pain. More than pain than either of my previous natural births.
I told them I was in transition. They sent me home.
This is how I had an unassisted home birth 15 minutes after I left the hospital. I live less than a 2 minutes drive from the hospital, but when my water broke there was no time. I screamed for my husband to get a towel and then said forget the towel come make sure the baby doesn’t hit the floor. One uncontrollable push later and we had a healthy baby.
My husband was elated we had avoided thousands of dollars in medical bills. He decided home birth was awesome. He loved that nobody could even offer me pain meds even though the expectation was that I would of course turn them down. The little bit of woo he had avoided up to this point he swallowed whole.
The reality is, I know a lot of home birthers who are self pay or have high deductible policies. Nobody says I want a home birth so I can save ten grand, so instead these hardworking middle class women buy the woo because they can’t afford the hospital. They can’t afford the epidural. They certainly can’t afford that expensive C-section recovery.
The reality is money is a much bigger motivator for natural childbirth/homebirth than anyone ever gives it credit for. Finding a way to offer lower cost hospital births would go a long way towards reducing homebirth and homebirth promoters. When families take the physical risk over the financial risk there is a high emotional buy in. With that buy in comes the need to convince themselves and also others that they made a good choice leading to an unforgiving, judgmental natural child birthing community.

fiftyfifty1

“The reality is money is a much bigger motivator for natural childbirth/homebirth than anyone ever gives it credit for.”
This is not the case around here. Our state has excellent coverage options. The majority of women who deliver at home around here are fully insured but pay good money out of pocket to deliver at home.

Allie P

All the women who do it around here are downright RICH and doing it for the lulz. I was asked TWICE at the swanky “wellness center ” (read: spa) in my upper middle class DC neighborhood where I went to get $100 pregnancy massage last week by other ladies sipping cucumber water at 2 in the afternoon if I was having a homebirth.

Adelaide

Just because some rich ladies choose homebirth for bragging rights doesn’t mean that some poor lady who would create financial stress for her family is making the same choice for the same reason. There are different types of people who choose homebirth. Chances are you are never going to change the mind of the rich lady who wants the superwoman homebirth cap, but the lady who jumps on the ncb/hb wagon for financial reasons might be talked out of it before she emotionally buys in by taking a gamble with her and her baby’s life. If I were you I wouldn’t throw my pearls to pigs. Don’t waste your breath on the rich lady, but look for solutions for the families living in the gray waters where the risk of complications is small and the financial outcomes are looking good.

theadequatemother

It’s not the case here either, because universal health care.

Adelaide

I’m not saying every homebirthing family chooses homebirth for monetary reasons. What I am saying is that there are a lot more families than it would seem at first glance. This might be a regional thing, but most homebirths in my small Appalachain town are undertaken by families that are self pay or have very high deductible policies. While I have no desire to ever homebirth again, not paying the $8000 deductible for our insurance is certainly appealing. I know other families who opted to have hospital births, but much like us waited to show up until the very end of labor and then left the hospital against medical advice prior to midnight the same day to avoid an additional “room” charge as they called it. Financially motivated medical decisions are real. It is often overlooked because instead of saying, “We don’t want to pay more money for that,” people say dumb stuff like “hospitals have germs so I’m going home now before my baby gets MRSA, bad gut flora, hospital cooties, and the Black Plague.

Daleth

“Financially motivated medical decisions are real.”

Why does it never occur to people facing real financial hardship that they could go to the hospital, have the baby there, get the bills in the mail and then just not pay them? What are they going to do, throw you in jail?

Adelaide

The families I know are not dirt poor, but they aren’t rich either. They don’t qualify for Medicaid and they have some small amount of assets that could be seized, and generally find the idea of not paying their bills unethical. I am speaking about the hardworking group in the middle that would never dream of just not paying their bills, but those bills will mean tightening their belts even more than they already are. They don’t choose homebirth because they feel they can’t go to the hospital, but their is a significant financial motivation to stay home. It isn’t every homebirther, but I do think it is a subgroup of homebirthers that could likely be talked into hospital birth. I can tell you I have personally talked several people out of homebirth. I share the risks of homebirth, but I also give them advise about minimizing their hospital bills (something that should be easier).

attitude devant

First of all, what The Adequate Mother says.
Second, there is a nice rundown of this in Gilbert Grant’s “Epidural Without Guilt,” a book I find so lucid and helpful that I keep copies for loan in all my exam rooms. There is EXTENSIVE literature on the timing of epidural, and the answer is “When she feels she needs it.” Seriously. One study on primips showed that women with epidurals actually delivered faster than women who were encouraged to wait. And there is extensive literature that regional anesthesia is associated with multiple benefits to mom and baby.

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com...
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